Psychologist-Vorlage
Pre assessment <18yrs
Eine professionelle Psychologist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This 'Pre-assessment <18yrs' template is designed for psychologists working with young people. It's a comprehensive tool for gathering essential information before a full assessment. The template covers key areas like presenting concerns, mental status, family history, and impact on daily functioning. This template is ideal for gathering information about a young person's mental health and well-being. Using Heidi, this template can be quickly populated from a session transcript, saving valuable time and ensuring all crucial details are captured. The date of this assessment is 1 November 2024.
Vorlagenvorschau
Reason for Assessment:
Patient referred by GP due to concerns regarding low mood and social withdrawal.
Mental Status Exam:
Appearance: Appears stated age, well-groomed.
Behaviour: Restless, fidgeting.
Speech patterns: Monotone, slow speech.
Mood: Low.
Affect: Restricted.
Thought process: Linear.
Orientation: Oriented to person, time, and place.
Previous/Current Engagement with Services:
Client reported no previous engagement with psychologist.
Client reported no historical and/or current engagement with allied health services.
Client reported no historical and/or current engagement with a paediatrician.
Client reported no historical and/or current engagement with a psychiatrist.
Diagnostic Information:
Client reported no diagnoses.
Current Medications:
Client reported no prescribed medication.
Presenting Concerns:
"I feel sad most of the time," the client stated. "I don't enjoy seeing my friends anymore."
Impact on Functioning:
Sleep: Difficulty falling asleep.
Social: Client reports withdrawing from social activities and feeling isolated.
Medical History:
Client reported no concerns regarding vision.
Client reported no concerns regarding hearing.
Client reported no serious medical conditions.
Family History:
Client reported no family history of mental health conditions.
Trauma History:
Client reports no traumatic events.
Pregnancy and Birth:
No complications reported during pregnancy or birth.
Early Development:
No reported concerns regarding developmental milestones.
No reported concerns regarding client's sleep pattern.
No reported concerns regarding client's eating habits.
No reported concerns regarding client's toileting skills.
School Environment:
Current school: St. Mary's High School
Year: Year 9
Academic Functioning: Presenting symptoms are not reported to impact academic functioning.
Assessment Plan:
Client's pre-assessment will be discussed at the Lighthouse Psychology Practice's assessment meeting.
Assessment goals: To assess the severity of the client's low mood and social withdrawal. Proposed questionnaires: Beck Depression Inventory (BDI-II), Social Avoidance and Distress Scale (SADS).
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